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Tel 516.492.3100
410 Lakeville Road
Suite 303
New Hyde Park
New York 11042
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Forms
In order to facilitate more convenient registration for appointments the forms below are available for download. If you are unable to download the forms then we will be happy to assist you in filling them out on your appointment day. If you need help filling out the forms in the office, please arrive 15 minutes earlier than your scheduled appointment time.
New Patient Medical Questionnaire - download pdf
New Patient Registration - download pdf
Notice of Privacy Practices - download pdf
Authorization to use/disclose health information - download pdf
This form authorizes Select Pain Consultants to release patient information to a specified party other than the patient.
Opioid Agreement - download pdf
This form outlines Select Pain Consultant's policies and procedures as well as the patient's responsibility in using narcotic medications appropriately.
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